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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHealthy Blue Louisiana Timely Filing Update | Open…
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    CurrentHealthy Blue LouisianaPolicy G-06050

    Claims Timely Filing

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    This policy governs when Healthy Blue Louisiana will consider reimbursement for initial claims and how timely filing limits are calculated. It applies to participating and nonparticipating providers and facilities, subject to applicable provider, state, federal, CMS, and contractual requirements.

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyClaims Timely Filing
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date06/03/2025
    Next Review DateN/A
    Key ActionSubmit the initial claim within the applicable timely filing limit and ensure that it is received and accepted by the health plan.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daysParticipating provider filing limit
    12 monthsNonparticipating provider filing limit
    Calendar daysFiling calculation basis
    3Related policies and materials

    Timely Filing Reimbursement Criteria

    Timely Filing Reimbursement Criteria

    Reimbursement for the initial claim is considered when the claim is received and accepted within the applicable timely filing limit, subject to controlling provider, state, federal, or CMS contracts and/or requirements.

    Reimbursement criteria

    • The initial claim was received and accepted within the applicable timely filing limit.

    • Applicable filing limit

      • An applicable federal or state mandate governs the filing limit; compare the number of days between the date of service and the date the health plan received the claim to that mandate.

      • No applicable federal or state mandate

        • Health plan standard

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyClaims Timely Filing
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date06/03/2025
    Next Review DateN/A
    Key ActionSubmit the initial claim within the applicable timely filing limit and ensure that it is received and accepted by the health plan.
    SourceLink
    On This Page
    Timely Filing Reimbursement CriteriaFiling Limits and Calculation RulesTimely Filing Submission RequirementsPolicy Definitions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    The provider or facility is participating.90 calendar days
  1. The provider or facility is nonparticipating.12 months

  2. Timely filing calculation

    • Calculate timely filing by subtracting the date of service from the date the health plan received the claim.
    • If services were rendered on consecutive days, count the filing limit from the last day of service.
    • Use calendar days unless otherwise specified.
    • If the member has other health insurance that is primary, count timely filing from the date of the other carrier's Explanation of Payment (EOP).
  3. A claim filed outside the applicable timely filing limit is not subject to reimbursement unless the provider presents documentation proving that a clean claim was filed within the applicable filing limit.

    4. Filing Limits and Calculation Rules

    Standard correct codingmixed
    No codes listed
    Participating provider or facility
    Timely filing limit90 days
    Applies toParticipating providers and facilities
    Controlling requirementsA provider, state, federal, or CMS contract or requirement may indicate otherwise
    Nonparticipating provider or facility
    Timely filing limit12 months
    Applies toNonparticipating providers and facilities
    Controlling requirementsA provider, state, federal, or CMS contract or requirement may indicate otherwise
    Consecutive-day services
    Calculation basisCount from the last day of service
    Applies whenServices are rendered on consecutive days
    Day-count standardLimits are based on calendar days unless otherwise specified
    Other insurance primary
    Calculation basisCount from the date of the other carrier's Explanation of Payment (EOP)
    Applies whenThe member has other health insurance that is primary
    Other carrier documentExplanation of Payment (EOP)

    Timely Filing Submission Requirements

    Billing Rule

    Submit claims within the filing limit

    Submit the initial claim within the applicable timely filing limit and ensure that it is received and accepted by the health plan. The standard is 90 days for participating providers and facilities and 12 months for nonparticipating providers and facilities, unless a controlling requirement applies.

    • Participating providers and facilities: 90 days.
    • Nonparticipating providers and facilities: 12 months.
    • Limits are based on calendar days unless otherwise specified.
    Documentation Required

    Document timely filing

    If a claim is filed outside the timely filing limit, provide documentation proving that a clean claim was filed within the applicable filing limit. Without this proof, the claim will not be subject to reimbursement.

    • Retain documentation showing timely submission of the clean claim.
    • The claim must have been filed within the applicable filing limit.
    Billing Rule

    Check controlling requirements

    Before applying the health plan’s standard timely filing limit, determine whether a controlling provider, state, federal, CMS, or contractual requirement applies. Timely filing is compared first to the applicable federal or state mandate; if none applies, the health plan standard is used.

    • Calculate the filing period from the date of service to the date the health plan receives the claim.
    • For consecutive-day services, count from the last day of service.
    • When other insurance is primary, count from the date of the other carrier’s Explanation of Payment (EOP).
    Documentation Required

    Apply disaster-related waivers

    Treat a temporary waiver of timely filing requirements as available only when authorized by the health plan following a documented natural disaster or under applicable state guidance. Do not assume that a disaster or other event automatically extends the filing limit.

    • The waiver is temporary.
    • Authorization must follow a documented natural disaster or applicable state guidance.

    Policy Definitions

    General Reimbursement Policy Definitions
    Governing definitionsGeneral Reimbursement Policy Definitions
    Definitions referenceGeneral Reimbursement Policy Definitions
    Policy definitions sectionGeneral Reimbursement Policy Definitions